Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 medication errors involved at least one high-alert medication. The investigation found that more than half of errors occurred during the administration process, and problems associated with set up and use of intravenous (IV) delivery systems contributed to omissions. Recommended strategies to reduce risks include developing standard procedures, tracing IV lines, and enhancing utilization of health care technology.